Is Breast Best? Does it Matter?

Before I get into this post, let me say I am pro-breastfeeding. The literature regarding health outcomes, for both mom and baby, has seemed fairly convincing, and I generally lean toward believing that our bodies know what to do to best provide for our children (assuming adequate nutrition and maternal health, that is).

Unfortunately, when I was 28 I felt I had to choose between breastfeeding and my own longevity, and I chose longevity. So while I long to nurse my daughter, I can’t. And many other women can’t either, for a variety of reasons. According to a 2013 CDC report, about 44% of infants born in 2008 were breastfed for at least 6 months and about 23% were breastfed for 12 months; that’s up from ~34% and 16%, respectively, in 2000. Conversely, that means that 56% of infants born in 2008 were not breastfed for 6 months. Aside from bilateral mastectomy, which probably does not account for all that many formula-fed babies, reasons cited for formula-feeding include difficulty with feeding (pain, latching, supply), support from medical professionals and family/peers, and a variety of other practical and medical reasons. Women of color are less likely than white women to initiate breastfeeding and less likely to continue if they do try at first (CDC report).

In general, the literature suggests that breastfeeding confers many health benefits for both mom and baby. Women who do not breastfeed tend to retain more weight post-partum and are at increased risk for chronic diseases including breast and ovarian cancer, obesity, and diabetes. For babies, formula-feeding has been shown to be one of many dietary factors associated with increased risk of obesity and has also been linked to reduced risk of infection, asthma, and improved cognitive performance, though a recent systematic review by the Cochrane collaboration supports only the link to reduced infections (not, notably, to obesity at 6.5 years).

Before I had a child I looked at this as purely an academic issue. Now it’s also an emotional issue and I’d be lying if I said I could be objective. If a paper comes out that suggests I’m giving my daughter as good of a chance, even almost as good of a chance, as breastfeeding would I have to admit it lifts me up a little.

Last week, a new study by Cynthia Colen and David Ramey came out stating that, essentially, the benefits of breastfeeding have been overstated. In a novel approach, the researchers compared not only children from different families who have been breast- and formula-fed, but also non-multiple siblings who were discordant for breastfeeding. This should theoretically control for many of the differing family factors that may also influence long-term health and cognitive outcomes. After adjusting for a number of covariates including respondent age, race, and a number of socioeconomic indicators, siblings who were discordant for breastfeeding did not differ on any of the outcome variables assessed, and the only variable that differed between families was hyperactivity. There are, of course, a number of weaknesses in this paper. Notably, though duration of breastfeeding was apparently included as a covariate in at least some of the analyses, mean duration of breastfeeding was not reported in the paper (see BabyAttachMode for a great discussion of this and other weaknesses). At the very least, dichotomous classification of feeding practices is likely to introduce appreciable error to the analyses and should be discussed in the paper. I’m disappointed that the reviewers apparently didn’t request it.

All of this brings me to the point of this post (which is not to pick apart research) and the reason for my potentially inflammatory title. Of course it matters that we provide the best start we can. But what if – what if – neither is better? What if formula-feeding is just as good as breastfeeding in terms of child health outcomes? As previously stated, approximately 56% of babies in the US aren’t breastfed for 6 months (and approximately 1/4 are never breastfed). Scientists involved with manufacturing infant formulas are trying to come up with the best formulation they can, trying to get as close as they can to breast milk. No, they’ll never be able to capture the variations in hormones and antibodies passed through breast milk – science can only do so much – but if the nutrition is good enough to give babies a really good start that is essentially the same as breastfeeding then HALLELUJAH.

We’ll never ensure that every baby born in this country, or in the world, is breastfed. But maybe we can give them just as good of a start with formula and that’s a good thing. Let’s try focusing on that for a while.